Leading Women Mentor Application Form Question Title * 1. Please complete the following questions Name Phone Email Question Title * 2. How did you hear about this program? Poster or advertisement Church bulletin Community Agency Other (please specify) Question Title * 3. Why do you want to be a mentor? Question Title * 4. We ask all mentors to dedicate 2-3 hours per month to their mentee. Is this a commitment you can make for the next 12 months? Yes No I can commit for 6 months Other (please specify) Question Title * 5. Why do you think you would make a good mentor? Question Title * 6. Please answer the following questions: Current Place of Employment: Current Position: Number of Years in Canada if first generation immigrant: Question Title * 7. Highest Level of Education: Some highschool, no diploma Highschool diploma Some college, no diploma College diploma Some University, no diploma University diploma Graduate degree Private college or technical training institute Other (please specify) Question Title * 8. I would like to mentor a woman who: Is interested in the same field as I work in Who is from the same country of origin I am willing to work with any woman Other (please specify) Question Title * 9. I would describe myself as an: Introvert Extrovert Mix Question Title * 10. Can you provide 3 professional references? They can be anyone who knows you well. Name and phone/email of reference #1 Name and phone/email of reference #2 Name and phone/email of reference #3 Done